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Technology Request Form

Technology Request Form

Teacher Name*

Date of Request*

Location*

Program Supervisor*

Process

Section 1 - Hardware

Hardware Request

Quantity

Is an IEP Objective Addressed

Yes

No

Cost

Specify Objective

Any additional installation or equipment needed

Describe how this equipment will be used to improve instructional goals and student engagement

Comments

Section 2 - Software/Apps

Software/App Request

Quantity

Is an IEP Objective Addressed

Yes

No

Cost

Specify Objective

Any additional installation or equipment needed

Describe how this equipment will be used to improve instructional goals and student engagement

Comments

Section 3 - Professional Development

What support do you need to be successful in the classroom (i.e. training, coaching, TaC support, etc.)?

For Office Use Only

Approval

Approved

Not approved

Need more information

Comments

Date Returned to Supervisor

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Williamsport

Williamsport Office
2400 Reach Road
PO Box 3609
Williamsport, PA 17701
570.323.8561 | 570.323.1738 Fax

Canton

Canton Office
33 Springbrook Drive
Canton, PA 17724
570.673.6001 | 570.673.6007 Fax

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